Acrochordon as a marker of metabolic syndrome – A cross-sectional study from South India

INTRODUCTION

Acrochordon or skin tag is a common, benign skin lesion which appears as a soft, skin-colored, or hyperpigmented protrusion on neck and major flexures.^[1] Acrochordon is considered as a cutaneous marker of metabolic syndrome with increased risk of cardiovascular disease, stroke, and diabetes mellitus.^[2] However, there are only a few studies from South India that have assessed the relation between acrochordon and metabolic syndrome, in spite of a high prevalence of metabolic syndrome in this region.^[3,4]

In this comparative, cross-sectional study, we have attempted to determine the association between acrochordon and metabolic syndrome. We also tried to determine the relation between the clinical characteristics of acrochordons (distribution, number, color, and morphology) and metabolic syndrome.

MATERIALS AND METHODS

A cross-sectional study was carried out among consecutive 100 patients with acrochordons who attended the outpatient clinic of dermatology department of a tertiary referral center in South India from January 2017 to December 2017. One hundred age- and gender-matched healthy controls without acrochordons were randomly selected from those who accompanied the patients who attended the dermatology outpatient department during the same period. Patients with known endocrinopathies such as Cushing’s syndrome, thyroid dysfunction, pheochromocytoma, and glucagonoma, patients with psoriasis, patients on systemic corticosteroids, and other drugs which could alter the metabolic parameters and pregnant females were excluded from both the groups. Ethics committee of the institution approved the study. Individual study participant gave written informed consent.

A pre-set proforma was used to collect data regarding patient characteristics and age of onset and duration of acrochordon. We recorded the personal and family history of hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease, in each study participant. We also noted the medications received by each study participant. We did a detailed clinical examination and recorded blood pressure (BP), pulse rate, waist circumference, height, weight, and body mass index (BMI). We classified the participants into those with normal BMI (BMI<25), overweight (BMI 25–29.9), and obese (BMI≥30).^[5]

We documented the distribution, size, number, color, and morphology of acrochordons.

We determined the fasting lipid profile and fasting blood sugar (FBS) level in cases and controls.

Metabolic syndrome was diagnosed using the International Diabetes Federation metabolic syndrome worldwide definition as followed: ^[6]

Waist circumference of >90 cm in men and >80 cm in women plus any two of the following:

1. Triglycerides >150 mg/dl (1.7 mmol/l) or treatment for elevated triglycerides

2. High-density lipoprotein (HDL) cholesterol <40 mg/dl (1 mmol/l) in men or <50 mg/dl (1.3 mmol/l) in women, or treatment for low HDL

3. Systolic BP >130 mmHg or diastolic BP >85 mmHg or treatment for hypertension or previous diagnosis of hypertension

4. Fasting plasma glucose >100 mg/dl (5.6 mmol/l) or previously diagnosed Type 2 diabetes mellitus.

Data were entered into Microsoft Excel and analyzed with SPSS Inc. IBM Company version 18 Chicago, SPSS Inc. (United States of America). Descriptive data that included numbers and percentages were calculated for all the categories. Categorical data were analyzed by Pearson’s Chi-square test. P < 0.05 was considered statistically significant.

RESULTS

The study participants included 52 women and 48 men in either group. About 80% of the patients belonged to the age group of 20–50 years [Table 1].

Duration of acrochordons was <2 years in 12 patients (12%) and longer than 6 years in 36 (36%). The majority (89/100, 89%) of the patients were asymptomatic. Nine (9%) patients complained of pruritus and 2 (2%) had pain. Three patients (3%) gave a history of rapid progression of acrochordons. Table 2 shows the clinical and laboratory profile of study participants.

Forty-three (43%) cases had skin tags on the neck alone and 35 (35%) had skin tags on multiple body sites [Table 3]. The majority of patients (69/100, 69%) had acrochordons of size <0.5 cm. Two (2%) patients had acrochordons which were more than 2 cm in size.

The number of acrochordons was 10 or <10 in most of the cases (73/100, 73%). The number of acrochordons was 11–15 in 10% (10/100) and more than 15 in 17% (17/100).

Forty-six patients (46%) had hyperpigmented skin tags, 45 (45%) had skin-colored lesions and single patient (1%) with vitiligo had depigmented lesions. Both skin-colored and hyperpigmented (mixed) skin tags were seen in 8 (8%) patients.

Forty-seven (47%) patients showed pedunculated acrochordons, 16 (16%) had sessile, dome-shaped lesions, 35 (35%) had both pedunculated and sessile lesions, and 2 (2%) had pedunculated and filiform lesions.

A statistically significant association was noted between the presence of acrochordons and family history of acrochordons (P < 0.001), personal habits of smoking (P = 0.02), consumption of alcohol (P < 0.001), personal history of hypertension (P = 0.01), dyslipidemia (P = 0.01), and coronary artery disease (P = 0.04) [Table 2].

Metabolic syndrome was more common in those with acrochordons (65%) when compared to controls (28%). The difference was significant (P < 0.001), [Table 2].

Among the components of metabolic syndrome, a significant association was noted between the presence of acrochordons and BP >130/85 mmHg (P < 0.001), low HDL cholesterol (P = 0.04), and fasting plasma glucose >100 mg/dl (P < 0.001) [Table 2].

Metabolic syndrome did not show any association with either the duration, or the evolution of acrochordons (whether the lesions showed a gradual or sudden onset).

Intragroup comparison of cases with respect to the distribution of acrochordons showed that those who manifested acrochordons limited to the axilla showed a significantly lower frequency of metabolic syndrome (P = 0.008) and its components such as increased waist circumference (P < 0.001), elevated triglyceride level (P = 0.01), high BP (P = 0.004), and elevated fasting plasma glucose level (P = 0.03) when compared to those who had lesions on other body sites with or without involvement of axilla [Table 3]. Comparison of cases with respect to the number of acrochordons showed no significant difference between those who had up to 10 and more than 10 lesions. No significant association was noted between the size of acrochordon and metabolic syndrome or its components. A significantly higher percentage of cases with coexistence of hyperpigmented and skin-colored acrochordons had elevated triglycerides (P < 0.001), low HDL (P < 0.001), and high BP (P = 0.001) in comparison those who showed only hyperpigmented or skin-colored or depigmented lesions [Tables 4 and 5]. A significant association was noted between the morphology of acrochordons and the frequency of metabolic syndrome, waist circumference, serum triglyceride level, serum HDL level, and fasting plasma glucose level. Less number of patients who manifested only sessile acrochordons had metabolic syndrome (P < 0.001) and its components such as increased waist circumference (P < 0.001), elevated triglyceride level (P = 0.02), low HDL (P < 0.001), and elevated plasma glucose level (P = 0.002), in comparison to those who manifested coexistence of pedunculated and sessile or pedunculated or pedunculated and filiform lesions [Tables 4 and 5].

DISCUSSION

In our study, more than 60% of patients belonged to the age group of 31–50 years. Safoury et al., have noted an increase in mean number of acrochordons with age, which reached a peak at 40–50 years.^[7]

We noted a slight female preponderance (1.1:1) among patients with acrochordon. This was comparable to a previous study from India, though a marked female predominance was reported by others.^[8,9]

Our observation of 65% of cases manifesting metabolic syndrome was higher than the 42% noted in the previous studies from South India in patients with acrochordons as well as in other diseases like psoriasis.^[10,11]

We found that increased waist circumference (77%), high FBS (61%), high BP (45%), and low levels of HDL (42%) contributed to a higher percentage of metabolic syndrome in our cases with acrochordons.

Increased waist circumference was noted in a majority (77%) of cases, but there was no significant difference from control group, which was contradictory to the previous studies.^[10,12] However, on calculating BMI, 42% of the cases were overweight and 12% were obese which were significant and in accordance with other studies.^[8,13] Plausible mechanisms for higher prevalence of acrochordons in obesity are hyperinsulinemia and increased leptin levels.^[14]

A high fasting blood glucose noted in 61% of our patients was comparable to many previous studies.^{[2,7,12,15-17]} The significant lipid abnormality noted in our patients was a low HDL, which was concurrent with other studies.^[7,9] Low levels of HDL irrespective of the serum levels of total cholesterol or low-density lipoprotein are considered as the strongest predictor of cardiovascular morbidity.^[18] We observed a high prevalence of hypertension in 45% of cases while a previous Indian study reported a frequency of 33% for the same.^[10]

Srivastava et al., reported that lesions over thigh, neck, and axilla were more likely to have metabolic syndrome.^[10] This was contrary to our observation of cases manifesting acrochordons limited to axilla showing a significant negative association with metabolic syndrome and its components such as abnormal waist circumference (P < 0.001), elevated triglyceride level (P = 0.01), high BP (P = 0.004), and elevated fasting plasma glucose level (P = 0.03) when compared to those who had lesions on other body sites with or without involvement of axilla.

The number or size of acrochordon showed no significant association with metabolic syndrome in our study. This was discordant with the observation of Rasi et al., who documented an association between number of acrochordons and high fasting plasma glucose level.^[19]

The lack of association between color of acrochordons and metabolic syndrome as observed by us was comparable to the previous studies.^[1,2] However, we noted a significant positive association between coexistence of hyperpigmented and skin-colored acrochordons and serum levels of triglycerides (P < 0.001), HDL (P < 0.001), and BP (P = 0.001).

Morphological patterns of acrochordon and its relation with metabolic syndrome are rarely reported. One previous study found no significant association between the two.^[10] We found that patients with sessile acrochordons were less likely to manifest metabolic syndrome (P < 0.001) or its components such as increased waist circumference (P < 0.001), elevated triglyceride level (P = 0.02), low HDL (P < 0.001), and elevated plasma glucose level (P = 0.002) in comparison to those with other morphological types.

CONCLUSION

In a comparative, cross-sectional study of 100 cases and 100 age- and gender-matched controls, we found a significant association between the presence of acrochordons and metabolic syndrome. Comparing cases with respect to distribution, number, color, and morphology of acrochordons, we found a significant association between distribution of acrochordons and metabolic syndrome and also between morphology of acrochordons and metabolic syndrome.